If your started out your day with the need to research the costs of physical therapy, we can help. The need for physical therapy is a serious thing as we age, and it’s even more serious given how much it typically costs. If you’re over 65, the good news is that the federal government’s Medicare plan will help you with those costs. The bad news is that it won’t cover all of them.

Medicare Part B helps pay for “medically necessary” physical and occupational therapy. It also helps with some speech language pathology services. All of these services must be performed and received on an outpatient basis. Additionally, there are limits called therapy caps from most outpatient providers.

Therapy caps limits

For 2016, the therapy cap limit is $1960 for physical therapy and speech language pathology services combined. The cap limit for occupational therapy is also $1960. However, you might be able to qualify for an exception to these cap limits. An exception will allow you to receive continued Medicare financial support even after you reach the 2016 limit. In order to meet the exception requirements, your therapist or provider must “establish your need for medically reasonable and necessary services and document this in your medical record,” according to Medicare’s official website. Additionally, your therapist or provider must “indicate on your Medicare claim for services above the therapy cap that your outpatient therapy services are medically reasonable and necessary.”

If you do qualify for an exception, be aware that there are additional limits on the process called thresholds. If you exceed the thresholds, Medicare will likely review your medical records and may deny further coverage. The threshold amounts for 2016 are $3700 for physical therapy and speech language pathology combined, and $3700 for occupational therapy. The key to sustaining your coverage is to make sure that your therapist documents the services and provides evidence that they are medically necessary to improve your condition.

Advance Benefit Notice of Noncoverage

If your therapist recommends a service that isn’t “reasonable and necessary” by Medicare’s definition, he or she is required to provide you with a written notice called an Advance Benefit Notice of Noncoverage. After reviewing this document, you will need to decide whether or not the additional services are worth paying for out of your own pocket.

In terms of costs, Medicare Part B usually covers up to 80% of the Medicare-approved amount for a given service. You will be responsible for paying the remaining 20% on top of the deductible costs and any applicable copay fees. Consult with your doctor or therapist to determine exactly how much your specific services will cost. Discuss the treatments and treatment schedule with your doctor or therapy provider to make sure that you don’t exceed Medicare’s cap limits. Finally, be sure to confirm that your doctor or therapist accepts Medicare assignments.

by Lindsay Malzone, Lindsay Malzone is the Medicare expert for Medigap.com. She's been contributing to many well-known publications as an industry expert since 2017. Her passion is educating Medicare beneficiaries on all their supplemental Medicare options so they can make an informed decision on their healthcare coverage.